Spinal Primer

Back pain and neck pain are common medical problems in the western world. In television, print, and the internet there is spine information overload . Often information is frankly snake oil or a scam. People read my blog biography, and ask me questions about spinal disease, or spine problems. They pose questions in the comment section and sometimes directly in e-mails. The proper response to these questions is "you need a complete history, physical exam, and diagnostic testing to provide you with any sort of treatment plan or any sort of diagnosis". This is completely impossible for me to do through an anonymous online source. That ethical barrier does not stop some from providing this type of advice online, or selling products that are useless. I thought it might be preventative and helpful to do a short primer in spinal anatomy, spinal treatment, and spinal pathology for people to reference. Although there is a great deal of artistry to spinal medicine. There are basic principles that I review regularly with my patients. The point of this post is to try to provide people with a better understanding of their pathology, and the science behind the treatment. This will hopefully prevent them from purchasing scam or useless medical treatments.

Medical Disclaimer: This post does not constitute medical advice. It is not a substitute for medical care, treatment, or evaluation. This post is for informational purposes only. Specifically, Brian Dunning did not personally evaluate, recommend, or pre-approve any of the content of this post. Skeptoid is not a medical site. It is a science education site. This post is strictly educational.

Your spine and spinal structures are a miracle of evolution. It is the fulcrum point for most of the major motion and weight-bearing activities of your body. It is a complex and balanced structure. It is not perfect. Like all parts of your body the spine ages. All spines share many commonalities and similar structures. That said, they are usually unique in many ways as well. For the purpose of this post I'll stick to simple anatomy and simple explanations. Hopefully, it will be easily graspable knowledge for a lay population. For simplicity, I will exclude trauma related pathology.

ON a basic level, the major structures of the spine are: intervertebral discs, vertebrae, spinal cord with associated nerve roots, musculature and ligaments.The Interveterbral discs between the vertebrae are the shock absorbers, as well as the major stability mechanism in the spine. Ligaments and musculature actually support the majority of your body weight, more than 60%. The structural bones of the spine, known as the vertebrae are the largest structural component. There are five major groups of vertebrae. The cervical spine is your neck. The thoracic spine is middle back. The lumbar spine extends from the lower back into the pelvis. The sacrum is part of your pelvic bones. The coccyx is your vestigial tail. I will review in more detail the anatomy of the discs when I review some of the pathology.

Imaging: There are many ways to image your spine. I will briefly review them as well as the pluses and minuses of each type of diagnostic test. Imaging of the spine does not make people feel better. It is important to understand that no spine imaging ever explains pain. The exception is terrible circumstances like cancer, infection, or major fractures. Identical problems on spine imaging can have vastly different symptoms. An individual may have days they feel better and days they feel worse, but the images look the same for the most part. As a general rule imaging is a good method to determine what can be done to fix the spine, it is not a good determinant of why you are in pain.

1. Plain radiographic x-rays-X-rays are important to determine structural abnormalities, broken bones, and alignment. They are limited because they do not define soft tissue structures very well, and they expose patients to radiation. Although minimal amounts. They do have one advantage over the more advanced imaging (besides cost). You can do comparison films with motion of the spine which is difficult with either of the next two tests.

2. Computerized Axial Tomography better known as cat scan. Cat scans produce a relatively high resolution three-dimensional x-ray image of your spine. This is probably the best way to evaluate the bony structures of your spine. It is also an excellent test for determining different types of lesions. It has two rather sizable downsides. It is a large amount of radiation, and it has a limited view of the soft tissue structures.

3. Magnetic Resonance Imaging, better known as MRI. MRI's downsides are mostly procedural. The test can be difficult to endure if you're claustrophobic. You cannot have it if you have any indwelling devices that are affected by magnets. Such as pacemakers or internal pumps. Most medical hardware especially put in after 1997 is not dangerous in any way in an MRI machine. The biggest problem with metal and MRIs is scatter. The metal blocks the image. The MRI is the best method to image the discs and neurological structures. It does fairly good images of the bony structures. It is also very safe, as far as we know the magnets pose no health risk.

It should be noted that even the best imaging has limits. There are structures that cannot be clearly seen in your spine even with the best imaging. Most overlapping ligaments and muscular structures are indiscernible from other ones. Most injury and damage in those structures is seen indirectly due to swelling.

Pathology:It is important to understand that our internal structures age like our external features. At certain ages certain structural abnormalities are common. Age-related changes to the back are fairly ubiquitous. The changes are very individual and there is a significant genetic component. This is similar to external age-related changes skin wrinkles, baldness, or a gray hairs. The age that your spinal structures begin to decline is different for everyone. There are a few lifestyle factors that accelerate degeneration of the back. Unfortunately there are no proven or effective methods to slow age-related degeneration of spine. Smoking is universally regarded as bad for you. When it comes to your spine there is a huge correlation between smoking and degeneration of the spine. There are several theoretical mechanisms. None proven. I believe the most plausible mechanism is that intervertebral discs obtain intracellular oxygen through a slow diffusion process rather than active circulation. The high levels of serum carbon monoxide in smokers probably interferes with the diffusion. In any case there are multiple lines of research indicating correlation between advanced early degenerative spine problems and smoking. High body mass index is another factor that can accelerate age-related degeneration. If you carry an extra 50 pounds of weight that is 200 to 250 extra pounds of weight that your lower lumbar spine has to flex and extend. Admittedly cervical problems are not truly affected by persons body mass index. I will often tell a patient who is in denial about their weight to go pick up a 40 pound bag of dog food in the supermarket and hold it for as long as they can. They will find when they put it down they feel much better. An extra 50 pounds of weight is essentially the same thing. Lifelong heavy physical labor of all types accelerates early spine degeneration. There are always exceptions to these rules. People can perform these risky behaviors and have none of the problems. I will often tell my patients,"You could run across a major highway at rush hour and not get hit by a car. You can be standing in front of your house in a quiet neighborhood and get hit by a car, but usually the opposite happens." I tell my spine patients to play the odds, minimize your risk. You have to live with the fact that there is no control of genetics(for now).

Age-related degeneration is not the only form of spine pathology. There are injury related problems. Some are significant. Some are not. There are many technical terms for the mechanical injury of the intervertebral disc. I will try to explain the most common misperceptions, and the factual nature of the terminology currently.

1. Disc bulge-As we age intervertebral discs can bulge due to injury. Generally disc bulges are combination of factors. Disc bulges are often painless. In general I tell people bulging discs are a common problem that happens with aging. It is generally not a concerning or unusual to find bulging discs even on back imaging in your 20's.

2. Annular tear-the annulus, which is a tough wrap that surrounds the soft gel like center of a disc(nucleus pulposa), can be ruptured. If the annulus is split there is usually swelling and inflammation visible on imaging. This usually does directly cause back pain and back spasm. From a mechanical standpoint it is a small injury.

3. Herniated disc-when someone uses the misnomer slipped disc this is generally what they mean. The internal structures of the disc have been compressed to the point where they ruptured through the annulus and extruded outside of the annulus. Usually into the empty space in the spine. Sometimes away from nerve and other structures. Sometimes towards nerves and other structures. In the neck and in the lower back is common for these discs to rupture towards your spinal cord. In the thoracic spine this is less common but still possible.

There are other assorted bony injuries which are relatively common. Most of these have to do with degenerative changes. Compression fractures happen primarily in elderly patients, usually due to advanced osteoporosis. Osteoarthritis of the lumbar spine and the cervical spine. These are changes in bone structures due to lack of poor cushioning from age-related disc degeneration. There are cases of vertebral instability usually due to a variety of causes including arthritis and degenerative disc disease as well as muscular and ligament weakening. Idiopathic scoliosis is not truly pathology. It is a congenital spine variant. In scoliosis spines are not able to keep up with normal growth during puberty. As their spines develop rapidly a curvature develops in what is called the sagittal plane. From front to back your supine is supposed to curve. From left to right your spine should be, for the most part, straight. This curvature is not always a problem. In addition it is not always the source of back pain to have misalignment. Despite chiropractic theory's claims. I will tell you subluxation of the spine is actually a very rare condition. The spine is a fairly stable structure. If it was not there would be constant spinal cord injury's and nerve damage with simple stress.

Treatment:Treatment of the spine is a controversial subject. Physicians and experts in the field have widely varying opinions based on research. You are a custom-built human your treatment needs to be a custom built treatment. That does not mean that you use untried or implausible treatments to make yourself feel better. In general there are two outcomes for spine pathology you heal, or you have some form of surgical repair. In my opinion, everything should be done to avoid surgical alternatives unless the pathology is a threat to nerve function. Most physicians try to treat your symptoms and give you time to heal yourself. Despite fanciful claims in the media about restoring the spine or rejuvenating the spine. Injury to the spine is a one-way street. You can heal your structures but they do not go back to the way they were before the injury. You can fix problems with surgery but that is not putting you back the way they were before the injury. That is just the state of current medical technology right now. Any claims outside of those two outcomes is either misleading, openly deceptive, or snake oil.

Concerning Symptoms: The symptoms people commonly worry about related to their backs. In general they are not correlated to any pathology.

1. clicking and popping of the neck or back-like gray hairs on your head if you live long enough you will one day develop clicking and popping in your neck and lower back. It is a sign of degeneration. It is not a sign of a bigger problem. It is similar to saying I have gray hairs on my head therefore they are causing my migraines. there are spine conditions that generate pain and they do click and pop, usually not concerning in absence of pain.

2. "my back goes out!"meaning some joint in their back displaces, or moves back into place-In any back injury your body will spasm in attempt to provide a natural splinting to the site of the injury. This is an evolutionary development probably originated from having to get away from enemies with an injury. In the modern world it is a dysfunctional adaptation. The spasms can cause spine to contract in addition to disabling pain. It can flex your spine in a normal functional way abnormally. It does not however mean that parts of your spinal column are slipping in and out of place. Again, if that in fact were happening you would suffer major permanent nerve injury. There are conditions with progressive instability that develops slowly. Nerves and nerve structures can adapt to slow degenerative displacement of the spine. Any large or rapid displacements of your spinal structure result generally in permanent paralysis.

3. The severity of the pain involved-pain is an important symptom, but it is not a definitive symptom. In other words, the amount of pain an individual is experiencing does not correlate well with the severity of the injury. There are patients that have massive disc herniations, displacement of the spinal cord, and compression fractures who have very little pain. There are also people that have completely normal spinal structures that have disabling pain. Pain is like the thoughts in your head. It is a completely individual experience. No one can feel your pain, no one can understand your pain, and there is no way you can adequately have anyone else know what you are feeling. The flipside of that coin is that pain does not correlate with the severity of injury.

4. A "lump" or protrusion along the spine-again, not involving trauma cases. Most of the important and sensitive structures of your back are underneath the skin, underneath your spinal cord and associated nerves. They cannot rupture protrude without causing some form of nerve damage. Most superficial abnormalities of the spine are related to muscle and soft tissue injuries. Occasionally they are skin issues. Cancerous lesions of the spine are almost always within the bone and not externally palpable. In most cases protruding spinal structures are benign.

I think that is about as much detail I can put into one post without turning Skeptoid into Web M.D. I hope this answers some of your questions about problems you may have had in the past relating to your spine. Or maybe some confusion you have about your condition.

As a last note I would like to point out that narcotic pain relievers are very effective medications. For acute spine injuries, surgery, broken bones, or terminal conditions opiates and non-opioid narcotic pain relievers are an excellent medications. However if you have a back or spinal condition that does not get better with time they are maladaptive. The medications will eventually result in increasing amounts of pain. This is directly due to your nervous system up-regulating the opiate nerve fibers that the medication is blocking. Take narcotics long enough and you will eventually alter your brain chemistry enough that you may never be able to stop them. You will still have pain despite the medicine. In my opinion it is better to deal with pain now. Rather than deal with pain that is 10 times worse three years from now. Find a method that does not hide the pain and learn to live with it. The research shows that in time the pain will overcome the medicine's ability to help you. Eventually your pain sensitivity will increase to the point where it will be more painful than you can imagine right now.

I am not just a cold heartless spine provider that is telling you to live with the pain. I herniated two vertebral discs in my back over a decade ago. For two years I had constant back pain as well as bilateral leg sciatica. I was miserable. I never took narcotics. I knew what the problems were. Eventually I got better. At the time I wasn't sure it would ever go away but it did. I don't want to live with that pain ever again. I still wouldn't take narcotics.

DNS voice recognition technology and software, please excuse minor grammatical/typographical errors

References:

1	Coste J, Delecoeuillerie G, Cohen de Lara A, et al. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ 1994; 308:577.
2	Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA 2010; 303:1295.
3	Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients’ own criteria. Spine (Phila Pa 1976) 1996; 21:2900.
4	Mehling WE, Gopisetty V, Bartmess E, et al. The prognosis of acute low back pain in primary care in the United States: a 2-year prospective cohort study. Spine (Phila Pa 1976) 2012; 37:678.
5	Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327:323.
6	Vroomen PC, de Krom MC, Knottnerus JA. Predicting the outcome of sciatica at short-term follow-up. Br J Gen Pract 2002; 52:119.
7	Vroomen PC, de Krom MC, Knottnerus JA. When does the patient with a disc herniation undergo lumbosacral discectomy? J Neurol Neurosurg Psychiatry 2000; 68:75.
8	Bush K, Cowan N, Katz DE, Gishen P. The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976) 1992; 17:1205.
9	Frymoyer JW. Back pain and sciatica. N Engl J Med 1988; 318:291.
10	Bozzao A, Gallucci M, Masciocchi C, et al. Lumbar disk herniation: MR imaging assessment of natural history in patients treated without surgery. Radiology 1992; 185:135.
11	Delauche-Cavallier MC, Budet C, Laredo JD, et al. Lumbar disc herniation. Computed tomography scan changes after conservative treatment of nerve root compression. Spine (Phila Pa 1976) 1992; 17:927.
12	Johnsson KE, Rosén I, Udén A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res 1992; :82.
13	Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976) 2005; 30:927.
14	Atlas SJ, Chang Y, Kammann E, et al. Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation. J Bone Joint Surg Am 2000; 82:4.
15	Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev 2010; :CD007612.
16	Vroomen PC, de Krom MC, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med 1999; 340:418.
17	Malmivaara A, Häkkinen U, Aro T, et al. The treatment of acute low back pain�"bed rest, exercises, or ordinary activity? N Engl J Med 1995; 332:351.
18	Roelofs PD, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; :CD000396.
19	Hancock MJ, Maher CG, Latimer J, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet 2007; 370:1638.
20	Veenema KR, Leahey N, Schneider S. Ketorolac versus meperidine: ED treatment of severe musculoskeletal low back pain. Am J Emerg Med 2000; 18:404.
21	Coats TL, Borenstein DG, Nangia NK, Brown MT. Effects of valdecoxib in the treatment of chronic low back pain: results of a randomized, placebo-controlled trial. Clin Ther 2004; 26:1249.
22	Chrubasik S, Künzel O, Model A, et al. Treatment of low back pain with a herbal or synthetic anti-rheumatic: a randomized controlled study. Willow bark extract for low back pain. Rheumatology (Oxford) 2001; 40:1388.
23	Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478.
24	Silverstein FE, Faich G, Goldstein JL, et al. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA 2000; 284:1247.
25	Scheiman JM, Yeomans ND, Talley NJ, et al. Prevention of ulcers by esomeprazole in at-risk patients using non-selective NSAIDs and COX-2 inhibitors. Am J Gastroenterol 2006; 101:701.
26	Mukherjee D, Nissen SE, Topol EJ. Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA 2001; 286:954.
27	McGettigan P, Henry D. Cardiovascular risk and inhibition of cyclooxygenase: a systematic review of the observational studies of selective and nonselective inhibitors of cyclooxygenase 2. JAMA 2006; 296:1633.
28	Towheed TE, Maxwell L, Judd MG, et al. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev 2006; :CD004257.
29	Larson AM, Polson J, Fontana RJ, et al. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology 2005; 42:1364.
30	Watkins PB, Kaplowitz N, Slattery JT, et al. Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial. JAMA 2006; 296:87.
31	van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev 2003; :CD004252.
32	Beebe FA, Barkin RL, Barkin S. A clinical and pharmacologic review of skeletal muscle relaxants for musculoskeletal conditions. Am J Ther 2005; 12:151.
33	www.fda.gov/medwatch/SAFETY/2007/safety07.htm#Zanaflex(Accessed on October 13, 2011).
34	Cherkin DC, Wheeler KJ, Barlow W, Deyo RA. Medication use for low back pain in primary care. Spine (Phila Pa 1976) 1998; 23:607.
35	Pareek A, Chandurkar N, Chandanwale AS, et al. Aceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone. Eur Spine J 2009; 18:1836.
36	Childers MK, Borenstein D, Brown RL, et al. Low-dose cyclobenzaprine versus combination therapy with ibuprofen for acute neck or back pain with muscle spasm: a randomized trial. Curr Med Res Opin 2005; 21:1485.
37	Chou R, Peterson K, Helfand M. Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. J Pain Symptom Manage 2004; 28:140.
38	Reeves RR, Carter OS, Pinkofsky HB, et al. Carisoprodol (soma): abuse potential and physician unawareness. J Addict Dis 1999;18:51.
39	Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 2007; 146:116.
40	Mullican WS, Lacy JR, TRAMAP-ANAG-006 Study Group. Tramadol/acetaminophen combination tablets and codeine/acetaminophen combination capsules for the management of chronic pain: a comparative trial. Clin Ther 2001; 23:1429.
41	Peloso PM, Fortin L, Beaulieu A, et al. Analgesic efficacy and safety of tramadol/ acetaminophen combination tablets (Ultracet) in treatment of chronic low back pain: a multicenter, outpatient, randomized, double blind, placebo controlled trial. J Rheumatol 2004; 31:2454.
42	Ruoff GE, Rosenthal N, Jordan D, et al. Tramadol/acetaminophen combination tablets for the treatment of chronic lower back pain: a multicenter, randomized, double-blind, placebo-controlled outpatient study. Clin Ther 2003; 25:1123.
43	Fordyce WE, Brockway JA, Bergman JA, Spengler D. Acute back pain: a control-group comparison of behavioral vs traditional management methods. J Behav Med 1986; 9:127.
44	Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend 2006; 81:103.
45	Reid MC, Engles-Horton LL, Weber MB, et al. Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med 2002; 17:173.
46	Porsman O, Friis H. Prolapsed lumbar disc treated with intramuscularly administered dexamethasonephosphate. A prospectively planned, double-blind, controlled clinical trial in 52 patients. Scand J Rheumatol 1979; 8:142.
47	Hedeboe J, Buhl M, Ramsing P. Effects of using dexamethasone and placebo in the treatment of prolapsed lumbar disc. Acta Neurol Scand 1982; 65:6.
48	Finckh A, Zufferey P, Schurch MA, et al. Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. A randomized controlled trial. Spine (Phila Pa 1976) 2006; 31:377.
49	Friedman BW, Holden L, Esses D, et al. Parenteral corticosteroids for Emergency Department patients with non-radicular low back pain. J Emerg Med 2006; 31:365.
50	Staiger TO, Gaster B, Sullivan MD, Deyo RA. Systematic review of antidepressants in the treatment of chronic low back pain. Spine (Phila Pa 1976) 2003; 28:2540.
51	Korhonen T, Karppinen J, Paimela L, et al. The treatment of disc-herniation-induced sciatica with infliximab: one-year follow-up results of FIRST II, a randomized controlled trial. Spine (Phila Pa 1976) 2006; 31:2759.
52	Brennan GP, Fritz JM, Hunter SJ, et al. Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine (Phila Pa 1976) 2006; 31:623.
53	Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine (Phila Pa 1976) 2003; 28:1363.
54	Faas A. Exercises: which ones are worth trying, for which patients, and when? Spine (Phila Pa 1976) 1996; 21:2874.
55	Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005; :CD000335.
56	Gellhorn AC, Chan L, Martin B, Friedly J. Management patterns in acute low back pain: the role of physical therapy. Spine (Phila Pa 1976) 2012; 37:775.
57	Sinclair SJ, Hogg-Johnson SH, Mondloch MV, Shields SA. The effectiveness of an early active intervention program for workers with soft-tissue injuries. The Early Claimant Cohort Study. Spine (Phila Pa 1976) 1997; 22:2919.
58	Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther 2011; 91:722.
59	Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev 2004; :CD000447.
60	Walker BF, French SD, Grant W, Green S. Combined chiropractic interventions for low-back pain. Cochrane Database Syst Rev 2010; :CD005427.
61	Hurwitz EL, Morgenstern H, Kominski GF, et al. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine (Phila Pa 1976) 2006; 31:611.
62	Eisenberg DM, Post DE, Davis RB, et al. Addition of choice of complementary therapies to usual care for acute low back pain: a randomized controlled trial. Spine (Phila Pa 1976) 2007; 32:151.
63	Jüni P, Battaglia M, Nüesch E, et al. A randomised controlled trial of spinal manipulative therapy in acute low back pain. Ann Rheum Dis 2009; 68:1420.
64	Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006; 15 Suppl 2:S192.
65	Bigos S, Bowyer O, Braen G, et al. Acute low back pain in adults. Clinic Practice Guideline No. 14. Agency for Health Care Policy and Research; US Department of Health and Human Services, Rockville, MD 1994.
66	Cherkin DC, Deyo RA, Battié M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998; 339:1021.
67	Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med 2005; 143:849.
68	Kalauokalani D, Cherkin DC, Sherman KJ, et al. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine (Phila Pa 1976) 2001; 26:1418.
69	Furlan AD, van Tulder MW, Cherkin DC, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005; :CD001351.
70	French SD, Cameron M, Walker BF, et al. Superficial heat or cold for low back pain. Cochrane Database Syst Rev 2006; :CD004750.
71	Nadler SF, Steiner DJ, Erasala GN, et al. Continuous low-level heatwrap therapy for treating acute nonspecific low back pain. Arch Phys Med Rehabil 2003; 84:329.
72	Nadler SF, Steiner DJ, Petty SR, et al. Overnight use of continuous low-level heatwrap therapy for relief of low back pain. Arch Phys Med Rehabil 2003; 84:335.
73	Nuhr M, Hoerauf K, Bertalanffy A, et al. Active warming during emergency transport relieves acute low back pain. Spine (Phila Pa 1976) 2004; 29:1499.
74	Clarke JA, van Tulder MW, Blomberg SE, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev 2007; :CD003010.
75	van Poppel MN, Koes BW, van der Ploeg T, et al. Lumbar supports and education for the prevention of low back pain in industry: a randomized controlled trial. JAMA 1998; 279:1789.
76	van Poppel MN, Hooftman WE, Koes BW. An update of a systematic review of controlled clinical trials on the primary prevention of back pain at the workplace. Occup Med (Lond) 2004; 54:345.
77	Van Tulder MW, Jellema P, van Poppel MN, et al. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev 2000; :CD001823.
78	Kovacs FM, Abraira V, Peña A, et al. Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial. Lancet 2003; 362:1599.
79	Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med 2001; 16:120.
80	Cherkin DC, Deyo RA, Street JH, et al. Pitfalls of patient education. Limited success of a program for back pain in primary care. Spine (Phila Pa 1976) 1996; 21:345.
81	Daltroy LH, Iversen MD, Larson MG, et al. A controlled trial of an educational program to prevent low back injuries. N Engl J Med 1997; 337:322.
82	Nelemans PJ, deBie RA, deVet HC, Sturmans F. Injection therapy for subacute and chronic benign low back pain. Spine (Phila Pa 1976) 2001; 26:501.
83	Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain 1995; 63:279.
84	Yelland MJ, Mar C, Pirozzo S, et al. Prolotherapy injections for chronic low-back pain. Cochrane Database Syst Rev 2004; :CD004059.
85	Paoloni M, Di Sante L, Cacchio A, et al. Intramuscular oxygen-ozone therapy in the treatment of acute back pain with lumbar disc herniation: a multicenter, randomized, double-blind, clinical trial of active and simulated lumbar paravertebral injection. Spine (Phila Pa 1976) 2009; 34:1337.
86	Foster L, Clapp L, Erickson M, Jabbari B. Botulinum toxin A and chronic low back pain: a randomized, double-blind study. Neurology 2001; 56:1290.
87	Institute of Medicine. Committee on Pain, Disability, and Chronic Illness Behavior. Pain and disability: Clinical, behavioral, and public policy perspectives, Osterweis M, Kleinman A, Mechanic D (Eds), National Academy Press, Washington, DC 1987.
88	Pinto RZ, Maher CG, Ferreira ML, et al. Epideral corticosteroid injections in the management of sciatica: A systematic review and meta-analysis. Ann Intern Med 2012.
89	Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med 1997; 336:1634.
90	Wilson-MacDonald J, Burt G, Griffin D, Glynn C. Epidural steroid injection for nerve root compression. A randomised, controlled trial. J Bone Joint Surg Br 2005; 87:352.
91	Carette S, Marcoux S, Truchon R, et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med 1991; 325:1002.
92	Genevay S, Viatte S, Finckh A, et al. Adalimumab in severe and acute sciatica: a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2010; 62:2339.
93	Loisel P, Abenhaim L, Durand P, et al. A population-based, randomized clinical trial on back pain management. Spine (Phila Pa 1976) 1997; 22:2911.
94	Linton SJ, van Tulder MW. Preventive interventions for back and neck pain problems: what is the evidence? Spine (Phila Pa 1976) 2001; 26:778.
95	Choi BK, Verbeek JH, Tam WW, Jiang JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev 2010; :CD006555.
96	Lahad A, Malter AD, Berg AO, Deyo RA. The effectiveness of four interventions for the prevention of low back pain. JAMA 1994; 272:1286.
97	Moore JE, Lorig K, von Korff M, et al. The Back Pain Helpbook, Perseus Books, Reading, MA 1999.
98	Katz JN, Parkinson G. Heal your aching back, McGraw-Hill, New York 2007.
99	Dunkin MA. All you need to know about back pain, Arthritis Foundation, Atlanta 2002